A case of pneumococcal peritonitis

Reprinted from the ‘Reports of the Society for the Study of Disease in
Children ’ VoL I, 1901.

A CASE OP PNEUMOCOCCAL PERITONITIS.

By J. H. BRYANT, M.D.

Harriet S — , aged four years, was admitted into Guy’s
Hospital under my care on May the 11th, 1901, for vomit-
ing and abdominal pain. She had always enjoyed good
health until the evening of May the 9tli, when she was
seized with severe vomiting after supper. She, vomited
about six times during the night. The sickness ceased on
the following morning, but she appeared to be very ill, and
would not take her food. On the morning of the 11th,
as she was much worse, and had not taken any food, she
was brought up to the hospital, and was at once admitted.
She had not been sick since the evening of the 9th.
The bowels were opened on the 10th, and the motion
appeared to be natural. There was no discharge of
blood or mucus from the rectum.

On admission the pulse was 140 to the minute, the
temperature 102-8° F., and the respirations 40 to the
minute. She appeared to be vei’y ill, and had a drawn
and anxious expression. The abdomen was tense, rigid,
and very tender all over. There was no particular pain or
tenderness in the right iliac fossa. There were no
physical signs of pleurisy or pneumonia. I saw the child
soon after admission, and came to the conclusion that she
Avas suffering from acute peritonitis or diaphragmatic
pleurisy, and I suggested the possibility of a pneumo-
coccal infection on account of the absence of any localising
symptoms of appendicitis or other diseases. Mr. Dunn
saAv the child with me shortly afterwards, and decided

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PNEUMOCOCCAL PERITONITIS.

not to operate, chiefly on account of the absence of
vomiting and constipation, and because be was inclined
to the view that her condition was due to diaphragmatic
pleurisy or pneumonia.

During the night she was decidedly worse ; the abdo-
men became more rigid and tender, but the drawn
anxious expression was not so well marked. She also
vomited three times, and it was with great difficulty that
she could retain any food.

On the morning of the 12th Mr. Dunn saw the child
with me again, and decided to operate. The abdomen
was opened in the median line, and general peritonitis
was found. There was a good deal of slightly turbid
fluid in the peritoneal cavity, and the intestines were
covered with flakes of pale greyish-yellow lymph. The
fluid had no odour. The appendix vermiformis appeared
to be a little swollen, and it was removed. A subsequent
examination showed no ulceration, and the swelling was
no more than could be accounted for by the peritonitis.
It was certainly not the primary focus of the peritonitis.
The peritoneal cavity was washed out, and a drainage-
tube was left in. I examined some of the peritoneal
fluid, staining some cover-glass preparations with Macono-
chie’s capsule stain, and found a number of capsulated
diplococci, which I considered were pneumococci. Cul-
tures were also taken, but no growth resulted.

After putting the child back to bed the pulse became
very feeble, and stimulants were administered. In the
afternoon she had an attack of profuse diarrhoea, which
was stopped with a starch and opium enema and bismuth.
As the pulse did not improve saline enemata and in-
fusions of saline solution into the axillae were administered.
During the night she became very restless, and continued
so all the following morning. She died suddenly on the
afternoon of the 13th, at 4.30 p.m. < '

I made the post-mortem examination twenty-one hours
after death. Rigor mortis was well marked. The body
was rather wasted and anaemic. There was general

PNEUMOCOCCAL PERITONITIS.

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acute pleurisy, both lungs being covered with light
greyish-yellow, thin recent lymph. There was a small
quantity of thin, slightly turbid serous fluid in both
pleural cavities. There was no pneumonic consolidation
of any part of either lung, and no evidence of any
commencing pneumonia. The larynx, trachea, and

bronchi appeared to be normal. There was no peri-
carditis. The heart weighed 51 grammes; it was healthy.
The arteries were normal. There was general acute
peritonitis. The peritoneal blood-vessels were congested.

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PNEUMOCOCCAL PERITONITIS.

The coils of intestine were adhering to each other by-
means of pale greyish-yellow lymph. In the pelvis there
was a little turbid serous fluid. There was no local
lesion to account for the peritonitis. There was no
ulceration of the stomach, duodenum, or small or large
intestine. The condition of the appendix vermiformis
has already been mentioned. There was no suppuration
of any of the abdominal viscera. The liver weighed 184
grammes, and the spleen 54 grammes ; they were both
normal. The kidneys weighed 102 grammes, and were
quite normal.

Cultures were taken from the blood in the right
ventricle, from the spleen, and from the pleural and peri-
toneal cavities. Pneumococci were found in pure culture in
the first three, and with staphylococci in the last. Micro-
scopical preparations from these sources also showed
capsulated diplococci. Mr. Pakes examined the cultures
and cover-glass preparations, and confirmed the opinion
that the diplococci were pneumococci.

Remarks. — The cause of death was pneumoccal septi-
caemia, for pneumococci were found in the heart, blood,
spleen, pleural and peritoneal cavities. The question
naturally arises as to the source and channel of the
infection. There was no obvious primary lesion found in
any part of the body, and the clinical and pathological
evidence pointed to the peritoneum as the first structure
to be attacked. Did the pneumococci first gain access to
the peritoneum through the alimentary canal and cause
acute peritonitis, and then infect the blood, or was it a
primary blood infection, the peritoneum being the first
structure to be attacked? I have brought forward this case
as one of pneumococcal peritonitis, as all the symptoms
pointed to the peritoneum as the structure to be first
implicated, there being no indication of the lungs or
pleura being involved ; and the post-mortem evidence also
corroborated this view, for the morbid changes were more
marked and advanced in the peritoneum than in the
pleura.

PNEUMOCOCCAL PERITONITIS.

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The case I have just recorded makes the third which I
have had the opportunity of investigating during the last
eighteen months. The appearance of the lymph, and
the character of the fluid, and the clinical history in each
of these cases reminded me very forcibly of several cases
I had seen some years ago, in which no local lesion was
found, and which were classified under the vague and
unsatisfactory heading idiopathic peritonitis. I am
of opinion that a large proportion, if not all, of these
so-called cases of idiopathic peritonitis would have proved
to have been due to pneumococcal infections had they
been examined from a bacteriological point of view.

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